lv Strike out any words not applicable (see rule 76). Strike out any words not applicable (see rule 76). lvii Strike out any words not applicable. (see rule 76). lvi lviii Signature of assignor or transmitter. Signature of transferee. lix lx Here insert full name, trade or business address, nationality and description. Additional numbers may be given in a signed schedule on the back of the form. lxii Date of acquisition of proprietorship. lxiii Here insert full particulars of the instrument of assignment or transmission, if any, or statement of case. lxiv Strike out any words not applicable. lxv Strike out any words not applicable. lxvi Strike out any words not applicable. lxi lxvii Signature. To be signed by the person making the declaration. lxviii lxix Signature and title of authority before whom declaration is made. Additional numbers may be given in a signed schedule on the back of the form lxxi Strike out one of these words lxxii Strike out one of these words lxxiii Signature lxxiv Here insert the name of the public authority ordering the change, and the date thereof lxxv Signature of the registered proprietor or user, as the case may be lxxvi Signature. lxxvii Signature. lxxviii Here insert words and reference number identifying the entry or application. lxx lxxix Signature. lxxx Here insert present name, address, and description of registered proprietor or registered user. lxxxi my or our lxxxii Strike out the words not applicable. lxxxiii Additional numbers may be given on a signed schedule on the back of the form. lxxxiv I am or we are. lxxxv Strike out the words not applicable. Strike out the words not applicable. lxxxvii Here state the circumstances under which the change of name took place. lxxxvi lxxxviii Signature. lxxxix Here insert the trade or business address and description of the applicant(s) or his (their firm). xc Here insert the trade or business address and description of the applicant(s) or his (their firm). xci Signature. xcii Here insert the trade or business address and description of the applicant(s) or his (their firm).